Epidemiology and management of Staphylococcus Aureus infective endocarditis in adult patients with congenital heart disease: A single tertiary center experience

https://doi.org/10.1016/j.ijcard.2022.04.078Get rights and content

Highlights

  • Staphylococcus aureus infective endocarditis (SAIE) is a life-threatening complication in adults with congenital heart disease (ACHD).

  • Almost two thirds of ACHD patients infected with SAIE in our cohort required surgery during admission.

  • In-hospital mortality due to SAIE was 8.1% in this cohort.

  • Ongoing educational investment on how to prevent and timely detect SAIE is warranted.

Abstract

Background

Infective endocarditis (IE) is a potentially lethal disease for adults with congenital heart disease (ACHD). Staphylococcus aureus (SA) is one of the commonest pathogens, identified in patients with ACHD and IE. This study aims to analyse the epidemiology, clinical characteristics and in-hospital management of IE due to SA (SAIE) in ACHD.

Methods

This is a single center retrospective study on documented episodes of SAIE in ACHD patients, treated at the Royal Brompton Hospital between 1999 and February 2020.

Results

Thirty-seven ACHD patients had an episode of SAIE (mean age 35.5 ± 14.9 years). More than half (51.3%), had a cardiac lesion of at least moderate complexity, with left ventricular outflow tract lesions being the most frequent. Twenty-four (64.9%) patients had a history of at least one previous open-heart surgery, and prosthetic material was used in 20 patients. A predisposing event was identified in 11 episodes (29.7%). Surgery was performed during the same admission in 24 (64.9%) patients, with early surgery (≤ 7 days from admission) performed in 12 patients. Early operation was associated with a shorter in-hospital stay compared to a later operation during the same admission or medical management [28.5 (IQR 23) vs. 43.5 (IQR 30) days, P = 0.028]. In-hospital mortality was 8.1%. Renal dysfunction at admission was associated with in-hospital multiorgan complications and/or death (OR 7.50, 95% CI, 1.18–47.67, P = 0.03).

Conclusion

SAIE remains a life-threatening complication, necessitating cardiac surgery in the majority of ACHD patients. Ongoing educational investment on prevention and timely SAIE detection is warranted.

Introduction

Infective endocarditis (IE) is a serious complication afflicting patients with congenital heart disease (CHD) and remains a leading cause of morbidity and mortality in this growing patient population [1]. The risk of IE in adults with CHD (ACHD) is substantially higher than in the general population, with an approximate incidence of 1.1 per 1000 patient-years, which in turn, varies significantly among different types of CHD [2]. Multiple invasive procedures in ACHD population has led to a changing landscape in the epidemiology of IE over the last years, with Streptococci being the commonest culprit for IE in these patients, followed by Staphylococcus aureus (SA) as the second most frequently isolated organism in blood cultures and an independent predictor of IE-related in hospital mortality [3]. In this context of evolving patient demographic and disease, characterization of the burden and management of SA related IE (SAIE) in ACHD population is important to define preventive strategies and improve patient outcomes.

This study aimed to analyse the epidemiology and clinical characteristics of SAIE in patients with ACHD, identify potentially preventable predisposing factors and examine in-hospital care and its impact on hospital stay, short- and long-term outcome.

Section snippets

Study design, participants and clinical variables

This is a single center retrospective cohort study on documented episodes of SAIE, with SA detected in at least one blood culture, in adults with CHD (≥ 16 years old) that have been treated for IE at the Royal Brompton Hospital between January 1999 and February 2020.

Demographic data, information on medical and surgical history, data on inpatient management and post discharge events and outcomes were retrieved for all patients from hospital records and designated database. A dataset has been

Baseline characteristics

Out of 290 IE cases in 261 patients with CHD that have been treated during this study period at the Royal Brompton hospital, 37 adult patients (81.1% male) were treated for an episode of SAIE (Supplementary File). Mean age at presentation was 35.5 ± 14.9 years. Three patients (8.1%) had a history of previous IE, that was not attributed to S. Aureus.

Table 1 shows baseline demographics and comorbidities of patients with SAIE. According to the 2020 ESC ACHD Guidelines classification [1], nearly

Discussion

This study demonstrates that SAIE in a contemporary cohort of patients with CHD treated in a large tertiary ACHD centre is associated with significant morbidity and in-hospital mortality. More than a third of our patients experienced multisystem complications and/or death, with an in-hospital mortality of 8.1%, while nearly two thirds of patients required cardiac surgery during the same admission. Importantly, patients who underwent early surgery (~1/3 of our cohort) and survived it, had a

Conclusion

SAIE remains a life-threatening complication among young adults with CHD, necessitating cardiac surgery in about two thirds of hospitalized patients. Early operation has been associated with a shorter in-hospital stay in our cohort. Renal dysfunction predisposes to a worse outcome. Larger prospective studies may identify more predisposing factors that can be modified and predictors of in-hospital mortality to assist with timing of surgery in SAIE. Ongoing educational investment on how to

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of Competing Interest

None declared.

Acknowledgements

Alexandra Arvanitaki is the recipient of the International Training and Research Fellowship EMAH Stiftung Karla Voellm, Krefeld, Germany.

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All authors listed take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.

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